Patient education: Breast reconstruction after mastectomy for cancer (The Basics)

What is breast reconstruction? — Breast reconstruction is surgery to rebuild a breast that was removed to treat or prevent cancer. Reconstruction can be done with implants, or using tissue taken from other parts of your body, called "flaps."

Surgery to remove a breast is called mastectomy. If you are planning to have a mastectomy, talk to your surgeon about reconstruction before you have the surgery. Your mastectomy might need to be done in a certain way for you to be able to have the type of reconstruction you want.

Do I need breast reconstruction after mastectomy? — No, the decision to have reconstruction is totally up to you. Some people feel better or more like themselves if they have reconstruction after mastectomy. The important thing is that you have a choice about what to do.

In some cases, both breasts need to be removed. This is called a "double mastectomy." It can be done if there is cancer in both breasts, or to prevent breast cancer if you are at high risk. If you have a double mastectomy, you can also choose whether or not to have both breasts reconstructed. Some people are comfortable having no breasts, and choose not to have reconstruction.

What if I decide not to have reconstruction? — If you decide not to have reconstruction, you can decide if you want to wear a special bra called a "mastectomy bra." It has a pocket for a soft plastic breast on the side where your breast was removed, or both sides if both breasts were removed. It can help you look more even if you have had 1 breast removed, and you might find that it helps your clothes fit better.

When can I have my breast reconstructed? — Breast reconstruction can be done at the time of mastectomy or later. The timing for you will depend on the stage of your cancer and what other treatments you need. Also, if you want to delay reconstruction for personal reasons, you can ask your doctor about doing that.

People who have early-stage cancer or are having a mastectomy to prevent cancer can have the reconstruction at the same time as their mastectomy. This is called "immediate reconstruction."

People with a higher-stage or large cancer sometimes need to have radiation after mastectomy. (Radiation is a treatment that kills cancer cells or stops them from growing.) Reconstruction might be delayed until the radiation treatment is finished. This is called "delayed reconstruction." The delay is needed because radiation could damage the reconstructed breast.

How can surgeons reconstruct a breast? — The 2 main ways are with implants or with flaps. There are several kinds of flaps. The best reconstruction approach for you depends on:

●How big your breasts are to begin with

●If you have excess body weight, and whether it affects your health – Your options also depend on how much extra body fat you have and where it is.

●Whether you have other health problems – Some types of reconstruction are not recommended for people with diabetes, heart or blood vessel disease, lung disease, or other problems.

●Whether you have had surgery before – Scar tissue from surgery might affect your options, such as where donor tissue can be taken from.

●Whether radiation therapy is planned – Some types of breast reconstruction are more likely to have problems related to radiation therapy.

●Your personal preferences – Some people prefer a shorter surgery and recovery time and choose implants for this reason. Some people do not wish to have artificial materials in their body and choose flaps.

How does reconstruction with an implant work? — A breast implant is basically a breast-shaped container that is filled with salt water (called "saline") or something that feels like gelatin (called "silicone"). The implant can be inserted partly or completely under a layer of muscle in the chest.

Getting an implant usually involves 2 steps:

●First, the surgeon inserts a device called an "expander." Often, another piece of material (called "ADM") is added to support the expander, and later the implant. The expander stretches the skin and muscle in the chest. The surgeon gradually adds more and more fluid to the expander until the skin and muscle are stretched enough for the size of the implant being used.

●Then, the surgeon does another surgery to replace the expander with the implant (figure 1). Implants are best for people with smaller breasts that don't droop.

How does reconstruction with a flap work? — A flap reconstruction uses tissue from another part of the body to create a new breast. That tissue might be rotated in place keeping its own blood supply (called a "pedicled" flap) or disconnected and then reattached to a new blood supply (called a "free" flap). How complicated the procedure is, and the risks involved, depend on the type of tissue used.

If you choose a flap, your options might include:

●Perforator flaps – A perforator flap (figure 2) is the most common type of flap used for breast reconstruction. It is usually taken from the belly. One type is called a "DIEP flap" (figure 2). The flap is made up of skin and fat, but not muscle. After surgery, the belly looks flatter, like it does after a "tummy tuck." Since there is no muscle removed, the belly is not weakened after this kind of flap.

For people who do not have enough belly fat, there might be other perforator flap options.

●TRAM flaps – A TRAM flap (figure 3) is also taken from the belly, but is made up of skin, fat, and muscle. Because the muscle is taken, the belly is weaker after surgery. There might also be a noticeable bulge where the muscle was removed, especially if both breasts are reconstructed with this type of flap.

●LD flap – A latissimus dorsi ("LD") flap is taken from the back and is made up of skin, fat, and muscle. People who have this kind of flap have a scar on their back, just beneath the level of the bra line. They often also get an implant, because there is not enough fat on the back to make a new breast (figure 4). An LD flap is more often used when other options are not available, or if a past reconstruction has not worked.

Will my nipple be reconstructed? — If you want it to be, yes. This is usually done a few months after the breast reconstruction is done. To make a new nipple, the surgeon can rearrange the tissue that is already there or use tissue from another part of the body. Surgeons can also tattoo the new nipple and area around the nipple (called the areola) to match the color of your other nipple and make it look three-dimensional.

Will my new breast match my other breast? — As much as possible, yes. But the new breast will never be exactly like the breast you had before or exactly like your other breast. Plus, you won't have normal feeling (sensation) in the new breast. If you don't like the difference between them, your surgeon might be able to make changes to the reconstructed breast, or operate on your other breast to make them look more similar.

Can I choose which kind of reconstruction to have? — Maybe. Only some of the reconstruction types will be appropriate for you. But if you think that you would rather have one type of reconstruction over another, ask your surgeon if that approach would work for you. They can tell you if your choice makes sense, and if not, why not.

What problems should I watch for after surgery? — Most people do not have serious problems after breast reconstruction. But there are some problems that can happen, either right after the surgery or later:

●If you had either type of reconstruction (implant or flap) – Problems can include infection, blood or fluid coming from the area where you had surgery, or pain that does not go away.

●If you had an implant – The most common problem is called "capsular contracture." This is when scar tissue around the implant becomes hard and tight. This can cause the breast to feel firm or sore, or change shape. Other possible problems include the implant deflating, bursting, or moving out of place.

In very rare cases, people with an implant can get a certain type of lymphoma years later. Lymphoma is a cancer of the lymphatic system, which is part of the body's immune (infection-fighting) system. If you have an implant, see your doctor regularly afterward. This way, they can check for, and treat, any problems.

●If you had a flap reconstruction – In some cases, the flap does not get enough blood. This can happen right after surgery, or sometimes later, and if it does, some or all of the flap might need to be removed. In this case, your surgeon will need to do more surgery to fix the reconstruction, or do another type of reconstruction. Some people can develop a bulge or hernia where the flap tissue was removed to make the flap. This might need to be fixed with surgery if it is causing problems.

Call your doctor or nurse if you think that you have any of these problems. Some of them need treatment right away.

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